Medicaid Fraud Control Unit Complaint Form

If you feel you have been the victim of or have information of Medicaid (AHCCCS) fraud; fraud in the administration of the Medicaid program; and abuse, neglect or financial exploitation occurring in Medicaid facilities or committed by Medicaid providers or their employee, please fill out the complaint form below, or download a printable complaint form here.

Name *

Street Address *

City, State, Zip Code *

Phone

E-mail Address *

Please complete if you are reportingan abuse, neglect, or financial exploitation case.

Victims' Full Name *

Suspect's Full Name *

Facility Name *

Facility Street Adress *

Facility City, State, Zip Code *

Facility Phone Number *

Facility Website

Details of Abuse/Neglect or Exploitation *

Please include Amount of Loss if reporting Exploitation

Witness Full Name

Witness Phone Number

Please complete if you are reporting Medicaid Fraud

Medicaid Provider *

Provider's Street Adress

Provider's City, State, Zip Code

Provider's Phone Number *

Details of Medicaid Fraud *

If you have contacted any other agencies, please include any names or case numbers

Declaration: By selecting "Yes" and submitting this form, I declare under penalty of perjury under the laws of the State of Arizona that the information in this Complaint is true and accurate. *